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    Please reference the contract number on each page of all forms and any accompanying correspondence. A newly completed form is required for all requests. Forms that have been reused will not be honored.

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    		NameDescriptionTransaction TypeForm NumberStates
    		Accelerated Benefit Claim Complete to file an accelerated benefit claim. Claims NZ1361 10/22 NY
    		Accelerated Benefit Claim Complete to file an accelerated benefit claim. Claims Z1361 12/23 AK, AL, AR, AZ, CA…
    AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY
    		A Consumer's Guide to MIB's Underwriting Services Describes MIB and explains consumer's rights to receive a copy of their record Life Insurance Policy Changes XADV9055 10/22 AK, AL, AR, AZ, CA…
    AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY
    		Activation of Lifetime Income Benefit Request Use this form to activate a Lifetime Income Benefit. Other Transactions X4391 06/20 AK, AL, AR, AZ, CA…
    AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY
    		Add-On Benefit Election/Termination Guaranteed Minimum Withdrawal Benefit Use this form to add or terminate a GMWB. Other Transactions V4390 08/23 AK, AL, AR, AZ, CA…
    AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY
    		Add-On Benefit Election/Termination Lifetime Income Rider/Lifetime Income Benefit Use this form to add or terminate a Lifetime Income Rider or Lifetime Income Benefit. Other Transactions X4390 12/23 AK, AL, AR, AZ, CA…
    AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY
    		Add-On Benefit Election Guaranteed Minimum Withdrawal Benefit Use this form to add a GMWB. Other Transactions NV4390 08/23 NY
    		Affidavit of LOST POLICY Use this form when a policy/contract is lost. Other Transactions X2028 01/21 AK, AL, AR, AZ, CA…
    AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY
    		Affidavit of lost Policy/Contract Use this form when a policy/contract is lost. Other Transactions N2028 04/24 NY
    		Annuity Direct Deposit Request Use to set up or change bank information for direct deposit into client's bank account. Withdrawal, Payments & Deposits X1091 01/21 AK, AL, AR, AZ, CA…
    AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY
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    Annuities are issued by Jackson National Life Insurance Company (Home Office: Lansing, Michigan) and in New York, annuities are issued by Jackson National Life Insurance Company of New York (Home Office: Purchase, New York). Variable products are distributed by Jackson National Life Distributors LLC. May not be available in all states and state variations may apply. These products have limitations and restrictions. Contact the Company for more information. Jackson is the marketing name for Jackson Financial Inc., Jackson National Life Insurance Company and Jackson National Life Insurance Company of New York.

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    Not FDIC/NCUA insured • Not bank/CU guaranteed • May lose value • Not a deposit • Not insured by any federal agency

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    CMC17302 04/23

    Jackson National Life Insurance Company
    1 Corporate Way
    Lansing, MI 48951